Asian Spine Journal

Review
216 Kyu Yeol Lee Article Asian Spine J 2014;8(2):216-223
Asian Spine J 2014;8(2):216-223 • http://dx.doi.org/10.4184/asj.2014.8.2.216

Comparison of Pyogenic Spondylitis and

Tuberculous Spondylitis
Kyu Yeol Lee
Department of Orthopedic Surgery, Dong-A Medical Center, Dong-A University College of Medicine, Busan, Korea

Pyogenic spondylitis and tuberculous spondylitis are common causes of spinal infection. It is difficult to differentiate tuberculous
spondylitis and pyogenic spondylitis clinically and radiologically. Recently magnetic resonance imaging has been reported to be
beneficial for early diagnosis and differential diagnosis of the spondylitis, and is being used extensively for diagnosis. However, the
diagnosis must be considered in combination with corresponding changes in clinical manifestations, radiological findings, blood and
tissue cultures and histopathological findings. Conservative treatments, including antimicrobial medications, are started initially.
Surgical treatments, which include anterior or posterior approach, single-stage or two-stage surgery, with or without instrumentation,
may be performed as indicated.

Keywords: Pyogenic spondylitis; Tuberous spondylitis; Differential diagnosis

Introduction tuberculous spondylitis from pyogenic spondylitis clini-

Pyogenic spondylitis and tuberculous spondylitis are
common causes of spinal infection. The current trend is a
decrease in spinal infections due to good nutritional and
hygienic status, but an increase in the resistant strains of
the organism of pyogenic spondylitis [1,2]. Tuberculous
spondylitis has been common in developing countries,
and the number of patients with the disease has also
been increasing recently in developed countries [1,3-5].
Tuberculosis of the spine accounts for 1% of all tuber-
culous infections, and 25% to 60% of all bone and joint
infections are caused by tuberculosis [1,6]. It is important
to differentiate tuberculous spondylitis from pyogenic
spondylitis, because proper treatment for the different
types may reduce the rate of disability and functional
impairment [1,6,7]. However, it is difficult to differentiate
cally and radiologically [8,9]. The objective of this review
is to discuss the symptoms, laboratory findings, magnetic
resonance imaging (MRI) evaluations and management
of the two spinal infections according to recent literature.
Classification
There are various classification methods for spine infec-
tions. The most basic is by the histologic response of the
host to the specific organism [10]. Aetiologically spinal
infections can be described as pyogenic, granulomatous
and parasitic. Most bacteria cause a pyogenic response,
whereas Mycobacteria, fungi, Brucella, and syphilis in-
duce granulomatous reactions [11,12]. Other ways of
classifying spinal infections are by the primary anatomic
location or spread route. Anatomical classifications in-

Received Aug 26, 2013; Revised Oct 14, 2013; Accepted Oct 16, 2013
Corresponding author: Kyu Yeol Lee
Department of Orthopedic Surgery, Dong-A Medical Center, Dong-A University College of Medicine,
26 Daesingongwon-ro, Seo-gu, Busan 602-715, Korea
Tel: +82-51-240-2867, Fax: +82-51-243-9764, E-mail: gylee@dau.ac.kr

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Copyright Ⓒ 2014 by Korean Society of Spine Surgery
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 Asian Spine Journal Comparison of pyogenic spondylitis and tuberculous spondylitis 217
clude vertebral osteomyelitis, discitis, and epidural ab-
scess. Hematogenous, direct inoculation and spread from
a contiguous source are also used in the categorization by
spread route.
Incidence
Various reports have stated that pyogenic spondylitis is
relatively rare and represents 0.15% to 3.9% of all osteo-
myelitis cases [13,14]. Vertebral osteomyelitis is more
common in the lumbar region, followed by thoracic and
cervical spine (less than 10%) [13-15]. Bone and joint
involvement develops in approximately 10% of patients
with tuberculosis, and half of these affected patients have
tuberculosis of the spine [12,16,17]. In several studies,
the thoracic spinal vertebrae have been found as the most
common areas of tuberous infection, followed by lumbar
and thoracolumbar spine (in descending order by rate).
In pyogenic spondylitis, the lumbar spine is the most
common area of infection, followed by thoracic and cer-
vical spine (less than 10%) [13,15,17,18].
Aetiology and Bacteriology
While a wide range of organisms have been associated
with spondylodiscitis (bacterial, Mycobacterial, fungal,
and parasitic), it remains primarily a monomicrobial
bacterial infection. Staphylococcus aureus is the predomi-
nant pathogen, accounting for half of non-tuberculous
cases (range, 20%–84%). Streptococci (viridans type and
b-haemolytic streptococci, particularly groups A and B)
and enterococci are well known to be causes of spondy-
lodiscitis (5%–20%) [19,20]. The most frequently isolated
gram-negative organisms are Escherichia coli, Pseudo-
monas species, and Proteus species. These are frequently
found in association with genitourinary tract infection.
In addition the probable sources of infection are those
of soft tissue and respiratory tract among others. Most
common causes of iatrogenic disc infection are spinal
surgery and invasive manipulation [21-23]. Tuberculous
spondylitis is most commonly caused by Mycobacterium
tuberculosis, but any species of Mycobacterium may be
responsible [24].
Pathogenesis and Pathology
Infective spondylitis may result from hematogenous
spread, direct external inoculation or from contiguous
tissues. The hematogenous arterial route is predominant,
allowing seeding of infection from distant sites onto the
vertebral column. Wiley and Trueta [25] demonstrated
that metaphyses and cartilaginous end plates are starting
areas for blood-borne infections, showing how bacteria
could easily spread hematogenously to the metaphyseal
region of adjacent vertebrae [26]. In pyogenic spondylitis,
once microorganisms enter in vascular arcades in the me-
taphysis, the infection spreads. The disc is destroyed by
bacterial enzymes in a manner similar to the destruction
of cartilage in septic arthritis. Pyogenic infection com-
monly involves the thoracic and lumbar spines. In con-
trast to pyogenic infections, tuberculous infection com-
monly results from venous spread, Batson’s paravertebral
venous plexus. Tuberculous spondylitis typically involves
initial destruction of the anteroinferior part of vertebral
bodies and may then spread beneath the anterior spinal
ligament, involving the anterosuperior aspect of adjacent
inferior vertebra. Further spread may result in adjacent
abscesses [27]. Anterior type involvement of the vertebral
bodies seems to be due to the extension of an abscess be-
neath the anterior longitudinal ligaments and the perios-
teum. However, tuberculous spondylitis does not destroy
the disc until very late in the disease.
Prevalence and Clinical Manifestation
Tuberculous spondylitis has been reported to entail a
relatively long, insidious progress from the occurrence
and diagnosis compared to pyogenic spondylitis [1,28].
Lee et al. [28] described that for pyogenic spondylitis, it
took on average 6.4 months for the occurrence of clinical
signs, which include non-specific pain, fever and neu-
rological manifestation from the compression on spinal
cord and nerve root. For tuberculous spondylitis, it was
11.2 months on average. Hence pyogenic spondylitis
takes a shorter duration for the clinical signs. Buchelt et
al. [2] reported that the prevalence period of tuberculous
spondylitis was significantly longer than that of pyogenic
spondylitis. In addition, Colmenero et al. [7] has re-
ported that tuberculous spondylitis has an approximately
6-months prevalence period. As for tuberculous spon-
dylitis, there were almost no clinical sings such as fever,
pain or swelling due to infection and entailed a gradual
progress of disease. However, pyogenic spondylitis most
likely entails severe pain and high fever [1,6]. The results
 218 Kyu Yeol Lee
Table 1. Distinctive clinical findings of pyogenic and tuberculous spondylitis
Variable Pyogenic spondylitis
Fever More frequent associated high fever
Age Relatively old
Duration to diagnosis Relatively short symptom to diagnosis interval
ESR, CRP Markedly increased ESR, CRP
ESR, erythrocyte sedimentation rate; CRP, C-reactive protein.
of the most distinctive clinical findings for pyogenic
and tuberculous spondylitis are summarized in Table 1
[28,29].
Diagnosis
The definitive diagnosis of spinal spondylitis can only be
made from microscopic or bacteriological examination
and culture of the infected tissue. However the diagnosis
must be considered in combination with corresponding
changes in clinical manifestations, radiological findings,
blood and tissue cultures and histopathological findings.
1. Laboratory evaluation
The erythrocyte sedimentation rate (ESR) and gram stain
and culture are the commonly used laboratory tests in the
diagnosis of pyogenic spine infections [30]. C-reactive
protein (CRP) has been shown to be helpful in the diag-
nosis of infection and has supplanted ESR as the laborato-
ry study of choice for assessing the presence of infection
[31]. Koo et al. [29] described that the ESR and CRP level
were significantly higher in the patients with pyogenic
spondylitis than tuberous spondylitis. Polymerase chain
reaction has been used to rapidly identify the presence of
mycobacterium in formaldehyde solution-fixed, paraffin-
embedded tissue specimens [32].
2. Plain radiologic evaluation
The earliest and most common radiographic finding is
narrowing of the disc space in pyogenic spondylitis. It is
due to the disc destruction by proteolytic enzyme and is
followed by irregularity of endplate from the bone de-
struction. In progression and healing of the disease, os-
teolytic changes are followed by new bone formation and
osteosclerotic changes at the vertebral margins [21,23].
The findings of plain radiographs for tuberous spondylitis
Asian Spine J 2014;8(2):216-223
Tuberculous spondylitis
Intermittent fever
Relatively young
Relatively long symptom to diagnosis interval
Mildly increased ESR, CRP
may vary depending on the pathologic type and chronic-
ity of the infection. In early tuberous spondylitis, the disc
space is preserved more than pyogenic spondylitis from
the lack of proteolytic enzyme. Radiographs may show
osteoporosis of body and irregularity of endplate, among
others.
3. Magnetic resonance imaging
MRI has been reported to be beneficial for early diagno-
sis and differential diagnosis of the spondylitis and is be-
ing extensively used for diagnosis [1,7,33-35]. The typical
MRI findings of acute vertebral myelitis are low signal
intensity in the T1-weighted images and high signal in-
tensity in the T2-weighted images, due to edema of bone
marrow in the infected area. However the value of dif-
ferential diagnosis is low, as there is no specific difference
in the contagious causes. In the chronic progress with de-
layed diagnosis, high signal intensity is sometimes shown
in the T1-weighted images [3,34,36,37]. In addition low
signal intensity is shown in both T1 and T2-weighted im-
ages, if vertebral body has progressed to a collapse and
has irregular endplate sclerosis. Hence contrast enhance-
ment images of the gadolinium are specifically required
[3,37]. As the MRI is generalized, specific opinions that
are beneficial to differential diagnosis of tuberculous
spondylitis are being reported by various authors (Figs.
1, 2). Representative opinions deal with abscess in the
vertebral body showing contrast enhancement in the pe-
ripheral rim, erosion of vertebral body surface, paraspinal
abscess with relatively clear border that shows contract
peripheral enhancement, extension of anterior longitu-
dinal ligament of the inflammatory tissue and relatively
preserved disk [8,34,38,39]. As for tuberculous spondy-
litis, it typically starts from the anterior cancellous bone
in the vertebral body followed by vertebral body starting
to be destructed, extending beneath anterior longitudinal
ligament and creating an abscess near the vertebral body
 Asian Spine Journal Comparison of pyogenic spondylitis and tuberculous spondylitis 219

[1,3,40]. Many of the studies dealing with tuberculous
spondylitis have reported that abscess involves uniquely
multiple vertebral bodies, especially in gadolinium-
enhanced MRIs [34,35,41]. Chang et al. [41] has reported
that aforementioned form of contrast enhancement is
completely shown in tuberculous spondylitis. Destruc-
tion of vertebral bodies in tuberculous spondylitis entails
more of such contrast enhancement. It is assumed that
abscess is formed more and also available to be used for
beneficial indices when performing a differential diag-
nosis. Epidural extension and epidural abscess formation
have been reported to be observed more in tuberculous
spondylitis [35,41]. As for paraspinal abscess formed in
tuberculous spondylitis, contrast enhancement is known
to be more easily performed in the rim of abscess, with
the importance of a differential diagnosis [4,41]. In other
words, paraspinal abscess is frequently found in pyogenic
spondylitis; but well-defined paraspinal abnormal signal,
thin and smooth abscess wall and presence of paraspinal
or intraspinal abscess are more suggestive of tuberculous
spondylitis than of pyogenic spondylitis. On the other
hand, if the wall of abscess is relatively thick entailing ir-
regular contrast enhancement, it has been reported to be
implying pyogenic spondylitis [30,34,42]. Chang et al.
[41] has reported that cases with grade 3 or above and
destructed more than 50% of vertebral body height were
observed in 82% of all cases in tuberculous spondylitis.
Such was observed in 30% of the cases in pyogenic spon-
dylitis. It was concluded that vertebral body was damaged
more severely in tuberculous spondylitis than in pyogenic
spondylitis. On the other hand, it has been reported that
disc is damaged more frequently in pyogenic spondylitis
[41,42]. Lack of proteolytic enzymes in Mycobacterium
as compared with agents of pyogenic infection has been
proposed as the cause of the relatively preserved interver-
tebral disc, found totally sequestered within the involved
vertebrae [1,3,12]. Chang et al. [41] has reported that
57% of a disc was preserved in tuberculous spondylitis,

A B C D
Fig. 1. Magnetic resonance imaging findings of tuberculous spondylitis in a 76-year-old woman. (A) T1 weighted sagittal image
demonstrates hypointense signal in T12–L2 vertebral bodies with epidural mass and subligamentous spread from T12 to L2. (B)
T2 weighted sagittal image shows heterogeneously hyperintense signal. (C) Contrast enhanced T1 sagittal weighted image shows
heterogenous enhancement of T12–L2 vertebral bodies. (D) Axial contrast enhanced T1 weighted image shows paraspinal abnor-
mal enhancement and paraspinal abscess-like lesion with peripheral well-enhanced thick wall.

A B C D
Fig. 2. Magnetic resonance imaging findings of pyogenic spondylitis in a 73-year-old man. (A) Sagittal T1 weighted image shows
diffusely decreased signal intensity in T11–T12 vertebral bodies. (B) On sagittal T2 weighted image, T11 and T12 vertebral bod-
ies are isointense to adjacent normal vertebrae. (C) Sagittal contrast enhanced T1 weighted image shows diffuse heterogenous
enhancement. Abscess is present in T11–T12 disc space extending to vertebral bodies. (D) Axial contrast enhanced T1 weighted
image shows thick and irregular rim enhancement of paraspinal abscess.
 220 Kyu Yeol Lee Asian Spine J 2014;8(2):216-223

Table 2. Magnetic resonance imaging findings of pyogenic and tuberculous spondylitis

Variable Pyogenic spondylitis Tuberculous spondylitis
Para- or intraspinal abscess Absence Presence
Abscess wall Thick and irregular Thin and smooth
Postcontrast paraspinal abnormal signal margin Ill-defined Well defined
Abscess with postcontrast rim enhancement Disc abscess Vertebral intraosseous abscess
Vertebral body enhancement pattern Homogeneous Heterogeneous and focal
Involvement of vertebral bodies Involvement ≤2 vertebral bodies Multiple body involvement
Commonly involved region Lumbar spine involvement Thoracic spine involvement
Degree of disc preservation Moderate to complete disc destruction Normal to mild disc destruction
Bony destruction more than half Infrequent and mild to moderate Frequent and more severe

while only 3% was preserved in pyogenic spondylitis. A
summary of data regarding the radiologic findings is in
Table 2 [4,41].
Treatment
The aim of treatment is to eradicate the infection, restore
and preserve the structure and function of the spine and
alleviate pain.
1. Conservative management
Conservative management consists of antimicrobial
therapy and non-pharmacological treatments, includ-
ing physiotherapy and immobilization. Immobilization
through bed rest is for pain control and prevention of
deformity or neurologic deterioration. Length of time for
bed rest, type of orthosis and duration of its use depend
on location of the infection, degree of bone destruction
and deformity and response to treatment. While initial
antimicrobial therapy is almost always administered
parenterally, its duration varies considerably. In several
studies, the mean parenteral treatment duration is at least
from 4 to 6 weeks, followed by oral conversion treatment
[11,12,20,43,44]. At present, it is recommended that par-
enteral antibiotic therapy be used in maximal dosage for
6 weeks and followed with an oral course of antibiotics
until a resolution of the disease. Criteria for discontinua-
tion of antimicrobial treatment include symptom resolu-
tion or improvement and the normalization of ESR or
CRP [20,45].
In tuberculous spondylitis, multiple drugs are used
because of the potential for resistance to a single agent.
Selection of rational combinations of drugs is based on
the mechanism of action and toxicity of the agents. A
6-month three-drug regimen including isoniazid, ri-
fampin and pyrazinamide is used for most cases of drug-
sensitive infection [24,46].
2. Surgical management
A surgical treatment is required in the following: to ac-
quire bacteriological or histological verification; if there
is severe pain; if clinically important abscess is formed; if
there is no response after injecting an appropriate antibi-
otic; if spine is deformed or such needs to be prevented
due to a severe damage to the bone; or if there is neuro-
logical paralysis [38,47-50]. An operation may be per-
formed to drain abscesses, to debride sequestered bone
and disc, to decompress the spinal cord or to stabilize the
spine for the prevention or correction of deformity. There
is a broad range of options for the surgical management
of spinal infections, which include anterior or posterior
approach, single-stage or two-stage surgery and with or
without instrumentation. Chen et al. [48] has described a
tendency toward a decrease in the incidence of infection
recurrence and revision surgery with combined approach
as compared with other approaches. Single-stage surgery
has advantages including lower complication rate, shorter
hospital stay and early mobilization. The two-stage
surgery has shorter operation time, less blood loss and
increased safety for patients with poorer general health
[51,52]. The efficacy of the two-staged operation did not
differ between the patients with pyogenic and tubercu-
lous spondylitis [53].
In most cases, the spine should be approached anteri-
orly, as it allows direct access to the infected tissues and
adequate debridement. The use of titanium mesh cages
 Asian Spine Journal Comparison of pyogenic spondylitis and tuberculous spondylitis 221
may provide better anterior column support, because
their structural integrity is not affected by degradative en-
zymes present in an infection environment. Interestingly
bacteria show lower propensity of adherence to titanium
compared with stainless steel [54-57]. The addition of
posterior instrumentation provides even better deformity
correction and faster rate of fusion and does not appear
to increase the risk of infection [54]. Single-stage anterior
and posterior surgery has been shown to be safe and ef-
fective using titanium implants [55,56]. Recent advances
in minimally invasive spine (MIS) techniques offer alter-
native methods of surgical treatment. Korovessis et al. [58]
showed in a small number of patients that anterior de-
bridement and reconstruction with titanium mesh cages
followed by posterior MIS screw fixation led to decreased
blood loss and shortened operative time.
In tuberculous spondylitis, most authors agree that
anterior radical debridement and strut graft fusion is
superior. The spine is approached anteriorly so that the
affected area may be dealt with most directly. Oga et al.
[59] evaluated the adherence properties of M. tuberculosis
and S. epidermidis to stainless steel. The Staphylococcus
heavily colonized the rods and was covered with a thick
biofilm, whereas only a few biofilm-covered colonies of
M. tuberculosis were seen. These findings have prompted
the use of anterior instrumentation at the time of initial
anterior debridement. Some authors recommend that a
posterior fusion should be performed in addition to an
anterior fusion in order to eliminate the risk of increased
deformity [60-62]. Anterior grafts may not provide stable
fixation, especially in cases where the graft spans more
than two-disc spaces [63].
Conclusions
Pyogenic spondylitis and tuberculous spondylitis entail
various types of clinical behavior, and a differential diag-
nosis is less likely to be conducted. It would be feasible for
clinical and radiologic indices to be beneficially utilized
on the differential diagnosis, before a culture examination
or pathologic examination is performed or in uncertain
situations.
Conflict of Interest
No potential conflict of interest relevant to this article
was reported.
Acknowledgments
This study was supported by Dong-A University Research
Funding.
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